Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 174N00000X | Lactation Consultant | 10421511 | VA |
Y | 207Q00000X | Family Doctor | 0101263837 | VA |
N | 207Q00000X | Family Doctor | 4301107153 | MI |
NPI | 1174926679 |
---|---|
Provider Name | Dr. Olufunmilola Modupe Ogbonlowo |
First Address | Lansdowne, VA 20176-1705 |
Second Address | Lansdowne, VA 20176-1705 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2014 |
Last Update Date | 30/11/2021 |